Breaking–The ‘more and worse’ experts predicted after WannaCry is here. In two days, the Petya or PetyaWrap (or NotPetya) ransomware has spread from Ukraine to affect organizations in 64 countries with 2,000+ attacks involving 12,000+ machines. On the hit list are mostly Eastern European and trans-national companies: Maersk shipping, Merck, Nuance cloud services, WPP advertising, Mars and Mondelez foods, Rosneft (Russia’s largest oil producer), Chernobyl, unnamed Norwegian firms, Beiersdorf and Reckitt Benckiser in India, Cadbury and law firm DLA Piper in Australia. One local US healthcare provider affected in a near-total shutdown of their computer systems, and resorting to backups, is Heritage Valley Health System in western Pennsylvania. There are no reports to this hour that the NHS, major US, Asia-Pacific, or European health systems being affected. Update: Trading in FedEx shares were halted 29 June due to the Petya attack on its TNT Express international division. Update 30 June: The Princeton Community Hospital in rural West Virginia is running on paper records as Petya forced a complete replacement of its EHR and computer hardware. Fox Business

Like WannaCry, the ransomware exploited the EternalBlue backdoor; a report from ArsTechnica UK adds an exploit touchingly dubbed EternalRomance. But unlike WannaCry, according to ZDNet, both “Symantec and Bitdefender have confirmed that it’s a Petya ransomware strain dubbed GoldenEye, which doesn’t just encrypt files — it also encrypts hard drives, rendering entire computers useless.” ArsTechnica goes deeper into methodology. Petya uses a hacking tool called MimiKatz to extract passwords and then uses legitimate Microsoft utilities and components to spread it. (Ed. note: if you have time for only one technical article, readArsTechnica’s as the latest and most detailed.)

The Microsoft patch–and Microsoft has just issued an update for Win10, which this Editor heartily recommends you download and install–while defending against WannaCry, still isn’t preventing the spread. It’s speedier than WannaCry, and that says a great deal. Its aim appears not to be ransom, but data destruction. Updated: this POV is confirmed in today’s ZDNet article confirming that Comae Technologies and Kaspersky Lab strongly believe that Petya is a ‘wiper’ designed to destroy data by forever blocking it on your hard drive.

One reason this new form of Petya is proving so effective is due to improved worm capabilities, allowing it to spread across infected networks, meaning that only one unpatched machine on a whole network needs to become infected in order for the whole operation to come crashing down.

Not only that, but cybersecurity researchers at Microsoft say the ransomware has multiple ‘lateral movement’ techniques, using file-shares to transfer the malware across the network, using legitimate functions to execute the payload and it even has trojan-like abilities to steal credentials.

** The inclusion of this link in the quote does not imply any recommendation by TTA, this Editor, or testing of said fix.

What you can do right now is to ensure every computer, every system, you own or are responsible for is fully updated with Microsoft and security patches. If you’re in an enterprise, consult your security provider. Run backups. Remind employees to not click on links in suspicious messages or odd links even from known senders–and report them immediately. Based on reports, phishing emails and watering hole attacks are the main vectors of spread, like WannaCry. (A suggestion from this Editor–limit web search to reputable sites, and don’t click on those advert links which are buggy anyway!) Be judicious on updates for your software except by Microsoft and your security provider; there is growing but still being debated evidence that the initial Ukrainian spread was through a hacked update on a popular tax accounting software, MeDoc. More on this in ZDNet’s 6 Quick Facts. Another suggestion from Wired: run two anti-virus programs on every computer you have, one free and one paid.

In last week’s Senate subcommittee hearings on the Federal Communications Commission (FCC)’s Universal Broadband Fund and Rural Healthcare (RHC) program, the University of Virginia’s Center for Telehealth chalked up some substantial results confirming the effectiveness of telemedicine in rural areas. In advocating further funding for an expansion of the program, they presented the following:

The UVA analysis also quantified travel savings in areas where medical and hospital care can be hours away–17 million miles of rural travel including 200,000 miles by high-risk pregnant mothers. For these mothers, NICU hospital days for the infants born to these patients were reduced by 39 percent compared to control patients and patient no-shows by 62 percent.

Karen Rheuban, MD, director and co-founder of the UVA Telehealth Center, recommended that the FCC continue to fund the RHC’s $400 million budget, with the caveat of exploring additional federal revenues should that budget be reduced. She also recommended that Medicaid and Medicare reimbursement for telehealth services be increased, the addition of wireless technologies, and including emergency providers and community paramedics in RHC funding. mHealth Intelligence, Subcommittee information and hearing video (archived webcast)

The years-long telemedicine battle in the populous state of New Jersey–the ever-contradictory home of history, high taxes, ‘the Boss’, Newark Airport, and some of the world’s finest beaches and resorts–has finally concluded with a strong win. Last Thursday, the NJ Legislature unanimously passed two bills that set telemedicine practice and payment standards. The General Assembly passed A.1464 and then hours later, the State Senate passed its bill (S.291). Governor Chris Christie had already indicated his support and his signature is expected once both bills are formally reconciled. The new regulations will be effective immediately.

The bill defines telemedicine as doctor-patient two-way videoconferencing and store-and-forward technology, omitting audio-only, email, texting, and fax as usual on the consults. Telehealth is defined as communications technologies including remote patient monitoring and telephone to support clinical health care, provider consultations, and health-related education. No pre-qualifying in-person visits are required to establish a “proper provider-patient relationship” except for conditions requiring treatment with Schedule II controlled dangerous substances. Another exception is for unpaid consults in the wake of an emergency or disaster–something that NJ is experienced with, having been hit hard in the past by hurricanes.

Healthcare providers (inclusive of doctors, nurses and other healthcare professionals) must be licensed in the state and telemedicine/telehealth organizations must register with and submit reports to the Department of Health. A seven-member Telemedicine and Telehealth Review Commission will be set up within six months and will review DOH reports that contain de-identified data on usage, diagnostic code, and payment. These public reports could provide valuable insights on the efficacy of telemedicine and telehealth treatment.

The bill includes full parity of telemedicine payment with in-person visits for both public (Medicaid, state benefit plans) and private insurance plans. There is also parity of a different type affecting mental health providers, with mental health screeners, screening services, and screening psychiatrists not being required to obtain a prior authorization or a waiver prior to engaging in telemedicine and telehealth. (more…)

Our Eye on Tenders, Susanne Woodman of BRE, takes us far afield to the islands for a pair of upcoming tenders:

Shetland Islands: A community alarm system is needed ‘way up North’ by their Social Work Service for sheltered housing and individual homes in mainland Shetland and its outer islands of Unst, Yell, Papa Stour, Foula, Fair Isle, and Skerries. Peripherals are also required such as smoke alarms, bed sensors, temperature extreme sensors, door exit sensors, fall detectors and passive infrared monitors. The tender is for a four-year renewable contract and due on July 10. Public Contracts Scotland

Ireland: The Health Service Executive (HSE) is seeking tenders for a telemedicine service to undertake home visits for North East Doctor on Call (NEDOC), a GP out of hours service. It will cover two treatment centres, Navan and Drogheda, for a period of six months and provide suitable means to cover home visit or treatment centre calls on the weekend and public holidays from 10am-8pm. Due date is July 26 at 1pm Irish time. EU Supply

click to enlargeUpdated. Good morning, Alexa! 3rings, the ‘smart plug’ that has been monitoring since 2015 a loved one’s or neighbor’s wellness through their daily use of a key home appliance like a kettle or TV, then reporting that activity via a mobile phone/smartphone app, has expanded to the Internet of Things (IoT) with the integration of the 3rings plug with Amazon Echo.

The 3rings plug works with Echo and the Alexa avatar in two ways. The first is for family members, friends or neighbors to ‘ask Alexa’ (the Echo unit) if their loved one is safe, similar to the mobile phone reports and alerts. The second is to place an Echo unit in that person’s home so that the person can directly ask Alexa to tell 3rings they need help. This also sends an immediate alert to their friends/family network.

To this Editor, 3rings founder Steve Purdham noted that with Amazon Echo, the 3rings system is now expandable and agnostic, through the addition of proprietary sensors dubbed “Things that Care” and other makers’ devices to the 3rings smart plug so that families have a fuller picture of the monitored person’s pattern of activity. 3rings Things monitor temperature, activity, motion, open/close of doors and windows, and button, and are priced a la carte or in a package with the Echo. The system also integrates with Samsung SmartThings, purchased separately, for additional types of monitoring. “Through this platform we want to stay ahead of the Internet of Things curve and demonstrate how technology can care.” Steve confirmed that the system is available now via a new website from the original (and still available) 3rings, with a group of users already on board. Full rollout is expected in August. Another advantage of integrating with Echo, according to Steve, is that the system can be offered in any location where Echo is. Also release

It seems like ages–in reality, only two years or so [TTA 19 Dec 15]–that this Editor was writing hopefully about advances in exoskeletons such as ReWalk and Wyss, EKSO plus DARPA research in assisting the mobility of paraplegics and others who need assistance in major movement. And then the news went rather dark, though ReWalk is now in its sixth iteration.

So it is heartening to be able to report that an established healthcare robotics company, Toronto’s Bionik Laboratories, is investing in a joint venture with Boston-based Wistron Corporation, an industrial design and manufacturing company, to further develop the Bionik ARKE lower body exoskeleton. Bionik’s emphasis has been on rehabilitative hospital-to-home upper body robotics to assist patients with regaining mobility. The ARKE appears to be both rehabilitative and assistive for patients in the home. Once developed in the JV, Wistron would be the sole manufacturer.

According to Crunchbase, Bionik raised $13.1 million in a July 2015 private placement specifically to develop the ARKE (MassDevice). This past May, they raised about $2 million from Hong Kong’s Ginger Capital in a separate JV to sell their robotics into the Chinese market. Bionik partnered with IBM starting last year to develop machine learning to analyze the data generated by the ARKE (FierceBiotech).

The target market for the Bionik/Wistron JV is not in this context a surprise. It is the booming older adult Asian market, where the aging/elderly population is projected to hit 983 million by 2050. Many especially in China and India live in rural areas and aren’t covered by any pension or old-age support (ADB Research). It is not clear to this Editor how expensive lower-body exoskeletons will be supported financially either privately or by government. Bionik release, FierceBiotech

click to enlargeWhile your Editor was on leave last week, it appears that Theranos may have grasped the thorn of Walgreens Boots Alliance’s lawsuit and settled. The Wall Street Journal(subscriber access only, largely reported on Fox Business) reported that Theranos told investors of a tentative settlement with Walgreens for less than $30 million.

Walgreens’ lawsuit, filed last year, was intended to recoup their $140 million investment in the company and store location payments. It surprised many observers that Walgreens would be content with 21 cents returned for every dollar of its investment, but since the original contribution took place over several years from 2010, much of this has likely been written down on Walgreens’ books as adjustments for bad debt.

But this seeming win for Theranos further rips the veil off their dire financial situation. Theranos also told investors recently that it is down to $54 million in cash, according to the WSJ/Fox Business. This is much reduced from their last report of $150 million in March [ch. 41]. With a monthly burn of $10 million a month, this would leave $120-130 million if the March estimate was correct. Part of the settlements, including Walgreens, may be covered by insurance policies. However, what has transpired since then may further account for the discrepancy.

In May, Theranos settled with Partner Fund Management (PFM) for an undisclosed amount which WSJ sources estimated at $40-50 million. They sought to claw back their $96 million investment. (more…)

Make your plans, if you have not already, to attend The King’s Fund’s annual Digital Health meeting in London. NHS England’s “Next steps on the five year forward view” outlines the plan to harness technology and innovation over the next two years. But what’s really happening on the ground? Tuesday features seven breakout sessions, a drinks reception, and speakers ranging from Rob Shaw, Interim Chief Executive, NHS Digital to Sarah Thew, Innovation and User Experience Manager, Greater Manchester Academic Health Science Network. Day 2 on Wednesday features an interactive panel discussion on NHS Test Beds, which are evaluating the real-world impact of new technologies, a breakfast workshop on integrating technology with care in Greater Bristol and eight more breakouts that cover everything from interoperability to self-care and patient engagement. The content is wide-ranging, fresh, and different. There’s also plenty of opportunities to network and also to see new technologies in the exhibition area. For more information and to register, click on the sidebar advert at right or here. #kfdigital17, @TheKingsFund TTA is pleased to be for another year a marketing supporter of the Digital Health conference.

Our Eye on Tenders, Susanne Woodman of BRE, has a new batch for your telehealth business consideration. (Thank you, Susanne!)

Scotland Excel: A Prior Information Notice (PIN) for suppliers of “digital dispersed alarm units that communicate information digitally between alarm unit and alarm centre”. They are invited to note interest to Scotland Excel and to demonstrate what digital equipment they can currently offer, including any relevant peripherals, such as alarm triggers. The estimated date for the contract notice is February 2018. More information on Public Contracts Scotland.

Leeds City Council: A £400k contract for telecare equipment is on offer for North East, Yorkshire and The Humber. This includes alarm units, fall detection, pendants, multiple sensors, and more. It is a 12 month framework with approval obtained to re-procure for the following two subsequent years, expiring 31st March 2020. Submit by 17 July. More information on Gov.UK.

General Medical Council, North West (Manchester) and London: An unusual tender for research comparing UK health regulators to counterparts in overseas countries (i.e. Canada, US, Australia, New Zealand or European member states). This covers the regulation of doctors, other healthcare providers (e.g. pharmacists) and healthcare services. Submit by 17 July. More information on Gov.UK.

Thurrock Council: This is for community alarm telecare monitoring and administration platforms, with all associated hardware required. Value stated is £100k – £500k, and contract ends 31 July 2021. Submit by 17 July. More information on Gov.UK.

Is it the technology, or the human touch? It’s only one study, but the sample size is substantial–450 patients–as was the length of time, one year. This randomized group in the Monitor Trial study published earlier this month in JAMA Internal Medicine came from 15 primary care practices in central North Carolina. All were over 30, were Type 2 diabetics who did not use insulin for control, and had glycemic control (hemoglobin A1c) levels higher than 6.5% but lower than 9.5%, which placed them higher than normal but within excellent to fair control (Endocrineweb.com). The 450 patients were divided into three groups: one with no self-monitoring of blood glucose (SMBG) but were monitored at their doctor’s office, another monitored themselves once daily, and once-daily SMBG with enhanced patient feedback including automatic tailored messages delivered via the Telcare meter (acquired by BioTelemetry in December ’16).

There were no statistically significant differences among the group either in the A1C or another measurement, health-related quality of life and “no notable differences in key adverse events including hypoglycemia frequency, health care utilization, or insulin initiation.”

It seems that in this relatively benign group, self-monitoring alone or mildly enhanced–in other words, patient engagement in SMBG–made no significant difference. The UNC-Chapel Hill researchers concluded that “This pattern suggests that, for SMBG to be an effective self-management tool in non-insulin-treated T2DM, the patient and physician must actively engage in performing, interpreting and acting on the SMBG values.” (Editor’s emphasis) In other words, more–not less–human contact would be needed for SMBG to work better, at least with this group! This Editor would then like to see a comparison with insulin control. Also Healthcare Dive

To respond to a recent contract Our Mobile Health needs to expand its pool of paid expert app reviewers. Applicants should be proficient health app users, professionally qualified, articulate and able to assess academic papers that justify app effectiveness. Reviews are done remotely (though reviewers must use the English version of apps) and offer an opportunity for reviewers to position themselves as digital health pioneers. Apply here.

Also, if you’re free in London, here are some events you may wish to consider:

Midsummer’s DHACA Day is at the Digital Catapult Centre, Euston Road, London on 21st June. It is aimed very much at digital health developers, with presentations on IP, new business opportunities, the new medical devices and data protection legislation and much more. DHACA membership remains free; entry to the event, which starts at 10 am for 10.30 am, is just the cost of lunch. Book here.

NICE is launching a new evidence tool for “medtech product developers” on 3rd July at the Royal Society of Obstetricians and Gynaecologists, 27 Sussex Place, London. Attendance is free though expect it to sell out soon! Book here.

The next Health Technology Forum meeting near Bank tube in London is on 5th July at 6.15 pm for 6.30 pm, starting with Giovanna Forte’s epic story of how to sell to the NHS – it’s really not to be missed! There’s also an important digital health dimension as she is looking for a partner to develop her innovation into an integrated service. This is followed by a talk on using digital health to provide acute paediatric care remotely. It’s free to attend though, if you book here, do please come along as otherwise it messes up our host Baker Botts’ kind and generous hospitality arrangements.

(Disclosure: this editor has an involvement in the majority of the above.)

Many of our Readers may consult HIStalk on occasion, especially the provocative weekly columns by a physician known as Dr. Jayne. She has a great deal to do with HIT for her practice, was a CMIO, and her Monday Curbside Consult is about the high cost of changing EHR platforms in a healthcare organization–an event that’s happening a lot lately (think DoD and VA). It’s the story of her friend who worked in IT for a health system that migrated to a single vendor platform and practice management system. The friend was given the option to remain with the legacy platforms support team for the transition, with the employer promising that those people would move to the new platform team following the migration. Routine, correct?

Not so routine when the cutover completion resulted in two weeks notice for those perhaps two dozen people. It wasn’t about headcount, because the organization posted jobs, but all new hires are required to be certified on the new system which the transition staff were not. And this health system, a non-profit, spent half a billion dollars for an EHR migration.

What’s the cost, in Dr. Jayne’s book?

The health system jettisoned a group of its most experienced people, with 15-20 years experience on average, with long-standing customer relationships (customers being doctors, practices, and health facilities). The knowledge base and track record they have in handling ‘Dr. Frazzled’s high maintenance billing team’, now wrestling with a new system, walked out the door.

These people, due to age, may never work, or find positions at the same level, ever again–and may very well wind up in the uncompensated healthcare system.

The health system may, through getting rid of experienced people, evaded the hard work on its own legacy of people and process. She points out that they “treated this migration simply as a technology swap-out” versus an “opportunity for further standardization and clinical transformation”. New people can freshen an organization, but will they be allowed to, or be fitted into the same stale setup?

Dr. Jayne is optimistic about her friend finding a new position. This Editor will let her write the conclusion which applies beyond HIT in how healthcare is being managed today, from small to giant organizations:

Too often, however, that mission is keeping up with the proverbial Joneses rather than being good stewards. It reminds me of when I was in the hospital this winter, when I didn’t get scheduled medications on time due to a staffing shortage. Is it really cheaper to risk a poor outcome? When did people become less valuable of an asset than mammoth IT systems or another outpatient imaging facility or ambulatory surgery center? And do we really need another glass and marble temple to healing when the actual patient care suffers?

On the lighter side of health tech, we celebrate Sir Paul McCartney’s 75th birthday (surely you jest!), his promotion to a Queen’s Companion of Honour and a few birthdays of people we know with this reworking of ‘When I’m Sixty-Four’ by one of our Readers (see below)

When I get older, thinking of health
Just two years from now

Seeing my doctor via video chat
Manage my vitals, ten seconds flat

Hey Dr. Dermo Is this a mole?
Or is it something more?

Manage my bills, reminders for pills
When I’m sixty-four

You’ll be older too
And if you click right here,
This can work for you.

Video for exercise and good things to eat
Keep me fit and trim
Feeling kind of sickly at a quarter to three
Need that prescription waiting for me.

Asking an expert is it sleep apnea?
Or just a very bad snore?
Manage my plans, sharing my scans
When I’m sixty-four.

Contributed by Howard Reis, founder of HEALTHePRACTICES in Westchester, NY, which performs business development and consulting for companies involved in all aspects of telemedicine. Their largest clients include a teleradiology service provider and a telehealth platform provider focused on remote patient monitoring and elder care.

(Note to Readers: Editor Donna is on leave this week. Regular postings will resume after June 26)

A study of a pilot telemedicine program, JeffConnect, administered by Thomas Jefferson University in Philadelphia during 2015 with 32 patients who received free primary care services via doctor-patient video consults (called telehealth here) has some interesting directional findings. The first was high overall satisfaction among the 19 respondents interviewed, including caregivers, with minimal wait times and far more convenience from home or work, aside from some difficulty in connecting. The second, and the most surprising, was this:

Patients had different perspectives on whether they prefer to hear bad news in a video call. Some said they preferred it, thinking that they could get the news earlier and be in a comfortable location with supportive people. One participant explained, “If it was something earth-shattering, you could cry in your own bedroom and not have to worry, I mean driving from downtown and you’re upset or what-not…” Others preferred to receive serious news in person, explaining, “If the doctor were telling me I have a fatal disease or a disease that could be fatal, and I have to go into immediate serious care, probably better in-person.” Several patients stated no clear preference between the 2 options.

Our supporter UK Telehealthcare‘s next TECS MarketPlace is moving up to West Yorkshire and hosted by CAIR UK at their headquarters. Approximately 35 industry leading Technology Enabled Care Services (TECS) suppliers and providers will exhibit their solutions. The day will also include exclusive behind the scenes tours of CAIR’s state of the art manufacturing facilities. The event is free to attend for all local authority and housing association representatives. More information is in the PDF attached, and register here on theUKTHC website.

Monday 26 June also kicks off Telehealthcare Awareness Week. Another associated event is Health + Care in London 28-29 June where UK Telehealthcare is a partner. More information on the event including bursaries for members is on their News & Events page (scroll down).

Upcoming MarketPlaces:

4th October 2017 – London MarketPlace, Barnet & Southgate College, High St. London N14 6BS

This Monday morning’s Big News was the stepping down, after 16 years, of GE‘s CEO Jeff Immelt effective August 1, and the rise of GE Healthcare’s head, John Flannery. The focus of most articles naturally was the fate of GE. Mr. Immelt may have steered the company through a severe recession starting in 2008, but he managed to lose about a third of the company’s value in the process. Expect some changes to be made in Boston. “I’m going to do a fast but deliberate, methodical review of the whole company,” Flannery told Reuters in an interview. “The board has encouraged me to come in and look at it afresh.” In an earlier call with investors, he said the review would have “no constraint.”

Mr. Flannery is a 30-year GE veteran, head of Healthcare since 2014, and previously head of GE India, its equity business in Latin America and GE Capital in Argentina and Chile. According to Fortune, GEHC is 15 percent of GE’s total business and in recent years has been smartly up in revenue. They have partnered recently with UCSF on predictive analytics, Boston Children’s Hospital on a pediatric brain scan database, and Johns Hopkins of a more efficient hospital bed allocation process. Also is an example of telemedicine remote diagnosis using a GE Health portable ECG device connected to the Tricog smartphone app to take a reading in India which was diagnosed in San Diego.

Usually healthcare CEOs become CEOs of other healthcare companies–witness the rise of one of Mr. Flannery’s predecessors, GE veteran Omar Ishrak, as CEO of Medtronic.Fortune’s healthcare reporter interviewed Mr. Flannery two weeks ago–more of this interview will be published according to the author. (But hasn’t as of June 21!)

Our definitions

Telehealth and Telecare Aware posts pointers to a broad range of news items. Authors of those items often use terms 'telecare' and telehealth' in inventive and idiosyncratic ways. Telecare Aware's editors can generally live with that variation. However, when we use these terms we usually mean:

• Telecare: from simple personal alarms (AKA pendant/panic/medical/social alarms, PERS, and so on) through to smart homes that focus on alerts for risk including, for example: falls; smoke; changes in daily activity patterns and 'wandering'. Telecare may also be used to confirm that someone is safe and to prompt them to take medication. The alert generates an appropriate response to the situation allowing someone to live more independently and confidently in their own home for longer.

• Telehealth: as in remote vital signs monitoring. Vital signs of patients with long term conditions are measured daily by devices at home and the data sent to a monitoring centre for response by a nurse or doctor if they fall outside predetermined norms. Telehealth has been shown to replace routine trips for check-ups; to speed interventions when health deteriorates, and to reduce stress by educating patients about their condition.

Telecare Aware's editors concentrate on what we perceive to be significant events and technological and other developments in telecare and telehealth. We make no apology for being independent and opinionated or for trying to be interesting rather than comprehensive.